Comparison of clinical characteristics and prognostic factors in two site-specific categories of ampullary cancer

BACKGROUND Ampullary cancer is a relatively rare malignant tumor in the digestive system.Its incidence has increased in recent years.As for now,its biological characteristics have not been fully clarified.Recent studies have primarily focused on the histological classification and genetic changes,but there are fewer investigations into the differences among site-specific subgroups.The clinicopathological charac-teristics of ampullary cancer occurring in different positions have not been elucidated.Furthermore,the role of adjuvant therapy in the treatment of patients with ampullary cancer remains controversial.ampullary cancer and explore the factors affecting prognosis.METHODS A total of 356 patients who met the inclusion and exclusion criteria were enrolled.Patients were divided into ampulla of Vater cancer(AVC)and duodenal papilla cancer(DPC)based on the gross and microscopic findings.Baseline data,admission examination results,and perioperative outcomes were collected and analyzed.The Kaplan-Meier curve was used for survival analysis.Univariate and multivariate analysis was performed to explore the independent risk factors affecting the overall survival(OS)of both groups.RESULTS The preoperative total bilirubin level in patients with AVC was significantly higher than those with DPC(P=0.04).The OS for patients with DPC was 58.90±38.74 months,significantly longer than 44.31±35.90 months for patients with AVC(P<0.01).The independent risk factors affecting the OS of AVC included:Preoperative albumin level(P=0.009),total bilirubin level(P=0.017),and number of positive lymph nodes(P=0.005).For DPC,risk factors included:Age(P=0.004),tumor size(P=0.023),number of positive lymph nodes(P=0.010)and adjuvant treatment(P=0.020).Adjuvant therapy significantly improved the OS rate of patients with DPC,but not for those with AVC.CONCLUSION Patients with AVC had a shorter OS compared to those with DPC.The prognosis factors and the role of adjuvant therapy of two groups were different.

Ampullary cancer of intestinal origin and duodenal cancer-A logical clinical and therapeutic subgroup in periampullary cancer

Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary(16%-50%), bile duct(5%-39%), and duodenal cancer(3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival(29-47 mo and 22-54 mo) compared to pancreatic cancer(13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.

Screening for hilar biliary invasion in ampullary cancer patients

BACKGROUND The treatment for ampullary cancer is pancreatoduodenectomy or local ampullectomy.However,effective methods for the preoperative investigation of hilar biliary invasion in ampullary cancer patients have not yet been identified.AIM To determine the necessity of and an appropriate method for investigating hilar biliary invasion of ampullary cancer.METHODS Among 43 ampullary cancer patients,34 underwent endoscopic treatment(n=9)or surgery(n=25).The use of imaging findings(thickening and enhancement of the bile duct wall on contrast-enhanced computed tomography,irregularity on endoscopic retrograde cholangiography,thickening of the entire bile duct wall on intraductal ultrasonography(IDUS),and partial thickening of the bile duct wall on IDUS)and biliary biopsy results for diagnosing hilar biliary invasion of ampullary cancer was compared.RESULTS Hilar invasion was not observed in every patient.Among the patients who did not undergo biliary stent insertion,the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results showed the highest accuracy(100%)for diagnosing hilar biliary invasion.However,each imaging method and biliary biopsy yielded some false-positive results.CONCLUSION Although some false-positive results were obtained with each method,the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results was useful for diagnosing hilar biliary invasion of ampullary cancer.However,hilar invasion of ampullary cancer is rare;therefore,the investigation of hilar biliary invasion of ampullary cancer might be unnecessary.

Association of metabolic syndromes and risk factors with ampullary tumors development: A case-control study in China

AIM: To evaluate the risk factors for ampullary adenoma and ampullary cancer.

Where does chemotherapy stands in the treatment of ampullary carcinoma? A review of literature

Ampullary carcinoma(AC) is a rare gastrointestinal tumor without clear treatment recommendations.The management of this tumor is usually extrapolated from the treatment of pancreatic,biliary duct and intestinal cancers.Few papers have studied the AC as an independent entity and yet succombs to several limitations.These studies were retrospective single institutional experiences with limited sample sizes recruited over a long period of time.Unlike metastatic ACs where chemotherapy is the only recommended option,localized AC once excised may be approached by either chemotherapy alone or concomitant chemoradiation therapy.In this review,we report the overall survival and recurrence factors of more than 1000 patients from all the studies treating exclusively ACs.We also review the medical treatment of this tumor and conclude to the necessity of multi-institutional randomized controlled studies for AC exclusively.

Differential c-erbB-1 and c-erbB-2 mRNA expression in cancer of the pancreas compared with cancer of the papilla of Vater

AIM： We examined quantitative mRNA expression of growth factor receptors （c-erbB-1, c-erbB-2） and the anti-apoptosis gene survivin known to be regulated in pancreatic adenocarcinomas and compared the expression pattern with that in carcinomas of the papilla of Vater. METHODS： Quantitative real-time reverse transcriptase- PCR （QRT-PCR, Taqman^TM） was performed to analyze mRNA expression levels of c-erbB-1, c-erbB-2 and survivin in normal and corresponding tumor samples of 31 pancreatic adenocarcinomas and 8 cancers of the papilla of Vater. RESULTS： The overall median mRNA expression of survivin was significantly increased in both adenocarcinoma of the pancreas （P〈0.01） and papilla of Vater （P〈0.008） compared with uninvolved normal control tissue. In pancreatic cancer, expression of c-erbB-1 was significantly decreased compared with the normal pancreatic tissue （P〈0.03）, whereas in the cancer of the papilla of Vater expression of c-erbB-2 was significantly downregulated （P〈0.05） compared with the paired normal samples. Gene expression was not associated with tumor stage, differentiation or prognosis. CONCLUSION： The common anti-apoptosis gene survivin is overexpressed both in the cancer of the papilla of Vater and pancreas. In contrast, the growth factor receptor genes c-erbB-1 and c-erbB-2 are differentially regulated in both tumor entities adding further evidence that pancreatic cancer is biologically different from the cancer of papilla of Vater.

Simultaneous Courvoisier's and double duct signs

Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system.The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown.We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging.The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma.